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Old 08-18-2016, 02:00 PM   #41
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We had a family member needing specialized surgery and our Kaiser doctor said they would have one of their staff doctors to do it - someone who did maybe three a year. We switched plans to use a specialist who has done thousands of this type of surgery instead. I don't want one of my family members to be a practice patient for major surgery. The surgeon we went to is actually is not on any insurance plan - he can set his rates as he pleases since he has specialized skills, but we picked a plan so the hospital and support services he uses are all in network.

We had other issues with Kaiser, too, like packed ER waiting rooms and overworked staff when the regular local hospital usually had no one waiting in the ER and attentive care.

That's my anecdotal experience.
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Old 08-18-2016, 02:47 PM   #42
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We had a family member needing specialized surgery and our Kaiser doctor said they would have one of their staff doctors to do it - someone who did maybe three a year. We switched plans to use a specialist who has done thousands of this type of surgery instead. I don't want one of my family members to be a practice patient for major surgery
Good move. Were you able to do this on the fly, or did you have to put the procedure off until year-end open season?

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Old 08-18-2016, 03:12 PM   #43
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Good move. Were you able to do this on the fly, or did you have to put the procedure off until year-end open season?

Ha
It was not an emergency surgery, so we had some time to research the best surgeon. Then during open enrollment we picked a plan that had the hospital the surgeon was affiliated with in their preferred provider network, so at least the hospital was in network and the insurance covered some but not all of the surgeon's fees.
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Old 08-18-2016, 04:24 PM   #44
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Often Kaiser will opt for an out of 'network' surgeon. For years they used a well known heart surgeon who was not a Kaiser physician and didn't practice at their hospital. http://www.ohsu.edu/xd/health/servic...rr/profile.cfm Bottom line: better results, cheaper for Kaiser.

You obviously researched insurance policies available to you, the same thing could have happened with any other PPO.
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Old 08-18-2016, 04:51 PM   #45
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Often Kaiser will opt for an out of 'network' surgeon. For years they used a well known heart surgeon who was not a Kaiser physician and didn't practice at their hospital. Dr. Starr's Profile | OHSU Knight Cardiovascular Institute | OHSU Bottom line: better results, cheaper for Kaiser.

You obviously researched insurance policies available to you, the same thing could have happened with any other PPO.
I don't know how many specialist kind of surgeons Kaiser has on staff compared to statewide PPO networks in California with the big insurance companies to know. There is also the ER room issue and a lot of things I didn't write up. YMMV. I personally am not a Kaiser fan based on my family's experiences for many issues.

The hospital the specialist surgeon operates at did have a long list of insurance carriers and plans they did accept.
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Old 08-18-2016, 06:28 PM   #46
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Kaiser did that for a complex pediatric heart case (child of a coworker). Multiple surgeries were done at Stanford. This was more than a decade ago, but I got the feeling it was cheaper to send the occasional patient out than to have a staff of surgeons capable of this level of work.
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Old 08-18-2016, 06:59 PM   #47
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Kaiser was a good idea for the Kaiser employees that had no health care for themselves or their families. The concept did not grow well. Once every employer in the East Bay saw the benefit, Kaiser became overcrowded and the quality of care deteriorated to that of the County hospital in Oakland. I could tell you over 50 years of Kaiser horror stories.

Things might be better at the Kaiser facilities outside of the Bay Area. The patient and employer demographics are probably better in San Diego and other higher income areas. But I would not enroll in Kaiser here under any circumstances. Too many bodies....
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Old 08-18-2016, 09:47 PM   #48
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I am from CA. When I retired in 2014 I signed up with Covered California, Blue Shield of California Gold 80/20 PPO policy, it cost $1,270/mo, husband and wife. I pay $1,362/mo now. I chose the Gold level to make sure that I am not restricted to a narrow network. I have not had problem accessing world class cares, from UCLA, USC, to private practices. I have had several MRIs, Ultrasounds, Biopsies, MOH surgery, Genetic Tests, Eye Specialists, etc., no problems.

There are private practices that do not take any insurance at all but these are minorities, based on my experience. Whenever I am seeing a new doctor, I would call their office to confirm that they accept my insurance. I have yet been in a situation where I was unable to find specialists that I needed.

The network directory was not as accurate in the beginning but has gotten a lot better, still it is better to call to verify that your insurance is accepted.

Give Blue Shield of California a try.


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Old 08-19-2016, 12:04 AM   #49
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I have never tried Kaiser but my feeling is if one can afford it, why not have maximum choice? If DH or I got cancer, I want to be able to go to the best docs, get the most advanced meds and treatments. All of the managed care organizations are VERY focused on managing costs. That priority could be a conflict of interest if we ever need state of the art, expensive treatments. We will keep our "grandfathered" pre-ACA PPO plan as long as we can afford it.


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Old 08-19-2016, 09:21 AM   #50
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I am surprised no one has mentioned the Consumer Reports write-ups on Health Insurance.

This publication is a good resource on all of these issues, and rates Kaiser very highly: Best Health Insurance Ratings & Reviews - Consumer Reports

You need to be a subscriber to click to the actual rankings, but much of the info is open. If you are really interested, go to your local library.

Disclosure of bias: I have been a satisfied private pay (now ACA) Kaiser member for 20+ years.
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Old 08-19-2016, 10:38 AM   #51
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As far as specialists at Kaiser. My husband had some a-fib issues several years back and was sent (by Kaiser) to a cardiologist at Scripps Memorial (non-Kaiser). This was bonus for us because it's much closer to our home.

My mother's ovarian cancer doctor was a super well respected "super doc" (major publications, etc.) Her chemo was managed by the regular oncologist - but under the supervision of the gyno-surgical super doc dude... When comparing notes with other patients - turns out this was the go to guy, and folks had actually switched to Kaiser to be able to use him.

In any insurance, getting a good primary doc is important. My dad's 2nd cancer experience (multiple myeloma)... he went in with shoulder pain... and the doc kept at it until they figured out it was blood cancer. My dad was kvetching the whole time about how the doc was trying to slap a terminal illness label on him. (Which it was... but that is not the doctor's fault). I have been very impressed with their oncology docs.
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Old 08-19-2016, 10:59 AM   #52
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I had Kaiser for most of my life when I lived in California. From my experiences and in talking to others, you either loved it or you hated it. We had a major Kaiser facility within a mile of our home, so we mostly loved it. There are catches -- it can (at least back then) take a bit longer for a routine appointment and generally (unless referred by Kaiser or emergencies) you are limited to Kaiser facilities for coverage. But there were no claim forms and, again at least at the time, little to no fighting with the insurance bureaucracy: if a Kaiser doctor declared a procedure to be medically necessary, it was covered.

I think I have shared this story here before but it bears repeating. In 2000, DW was recommended for braces and the orthodontist recommended jaw surgery to correct the jawline before the braces went on. As far as we can tell, that wasn't usually considered a necessary covered service under many medical plans. But we went to a Kaiser doctor who referred us to a specialist in orthognathic surgery at a Kaiser facility in Oakland, about 40 miles from where we lived at the time. He reviewed the orthodontist's findings, took some X-rays and concluded it would be medically necessary in order to minimize almost certain head and TMJ problems in the future. So all we paid (remember this was 16+ years ago) for the surgery was a $10 copay. Normally the procedure would have cost in the $15-20K range. We didn't have to fight it or take it to insurance company bureaucrats and beancounters. A Kaiser doctor indicated it was necessary, so it was covered -- end of story.

So yeah, we sort of became Kaiser fans after that. I don't know if that model still fully applies there (and I know it would be a lot more than just a $10 copay!), but at the time, it takes a LOT of the "are they or aren't they in the network" stresses out of the picture. Treated by a Kaiser doctor, in a Kaiser facility, at the direction of a Kaiser PCP and specialists.... it's covered with no potential for balance billing sticker shock. If we lived in a region that was served by Kaiser and we have sufficient facilities close by, yeah, we'd go back.
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Old 08-19-2016, 11:30 AM   #53
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ziggy - I had a similar discussion with a Kaiser doc about what might be considered an optional surgery. I was pregnant with my 2nd son, and my mom had died of ovarian cancer 2 years previously. Kaiser offered to do tubal ligation (if you requested it in advance) if you had a c-section... in order to take advantage of you already being opened up, surgically. I asked my doc about whether I could do a prophylactic oophorectomy instead of tubal ligation if I ended up with a c-section... we discussed my reasoning (family history of ovarian and breast cancer... the fact that I was already in my 40's and so not that early to trigger menopause.) She said it was unusual, but I had a compelling case. We also talked about the downsides (issues with nursing the baby, etc.)

I was very impressed that the doctor could approve it - it would be covered, if you had legitimate medical concerns. I ended up not doing the surgery because I didn't have a c-section and then decided to just let nature take it's course.
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Old 08-19-2016, 01:28 PM   #54
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Kaiser was a good idea for the Kaiser employees that had no health care for themselves or their families. The concept did not grow well. Once every employer in the East Bay saw the benefit, Kaiser became overcrowded and the quality of care deteriorated to that of the County hospital in Oakland. I could tell you over 50 years of Kaiser horror stories.

Things might be better at the Kaiser facilities outside of the Bay Area. The patient and employer demographics are probably better in San Diego and other higher income areas. But I would not enroll in Kaiser here under any circumstances. Too many bodies....
That pretty much sums up my experience. The local ER situation alone is enough to keep me from ever going back. We have Blue Cross now and have been happy with their plan and PPO network.
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Old 08-19-2016, 01:55 PM   #55
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I'm surprised by the ER comments. As you all know - last year was the year my sons decided to have a variety of ER requiring sports injuries. In everycase they did appropriate triage and we were taken back quickly. In fact, with my son's broken face (baseball at high speed to the orbital socket) they pulled us out of line before we'd even checked in. I guess the blood and swelling were clues. LOL.

We had a much longer wait at Sharp Hospital (DH has Sharp HMO) when he had to go to the ER last fall.

One more thing I like about Kaiser is their urgent care system. As a mom with kids that used to spike fevers during non-office hours - this was awesome. Just last week I used urgent care for my son's sore back-hip. My ped was on vacation so they suggested urgent care. My son was seen quickly and the dx was prompt and treatment seems to be working.
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Old 08-19-2016, 02:16 PM   #56
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Good to hear so many people like Kaiser. We may end up there someday. The Lynette Rahm case scared me a bit - young girl won $28M lawsuit because not one but two Kaiser docs refused her an MRI and she lost her leg, part of her spine and pelvic bone when it was finally diagnosed as cancer 2+ years after her parents asked for MRI to be done. I don't think docs in independent practices would have been so hesitant.


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Old 08-19-2016, 03:24 PM   #57
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Heck, a playmate of one of my kids had a diagnosis of asthma by her non-Kaiser pediatrician, the mother was very concerned and needed an ok for her daughter to play soccer - approval granted. One day, nebulizer at the ready, the child collapsed on the soccer field and died. She had a hole in her heart, not asthma.

IMHO seek second opinions, even third opinions. If you pay for an MRI that wasn't prescribed and it identifies the problem send the MRI bill to the insurer. Kaiser NW will pay for a second opinion and the docs at a place like OHSU have no compunction about offering a different point of view. Even if you end up paying the bill at least you know every last possibility has been explored. Trust but verify.

Physicians make mistakes, a Stanford neurosurgeon make a big one years ago while treating a cousin's wife (CA public employee's insurance). There is a reason why doctors carry malpractice insurance.
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Old 08-19-2016, 03:28 PM   #58
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Good to hear so many people like Kaiser. We may end up there someday. The Lynette Rahm case scared me a bit - young girl won $28M lawsuit because not one but two Kaiser docs refused her an MRI and she lost her leg, part of her spine and pelvic bone when it was finally diagnosed as cancer 2+ years after her parents asked for MRI to be done. I don't think docs in independent practices would have been so hesitant.
Yeah, I know. The thing is, there are millions of data points every year, no matter where you go. There are always going to be a handful of really bad decisions and bad outcomes. I think the best we can do is look at (relatively) objective statistics on outcomes and instances of fighting the insurance bureaucracy. I haven't looked into those for Kaiser in the last 13+ years since we moved to a place where they aren't around.
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Old 08-19-2016, 07:56 PM   #59
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Ooops, my bad. I should have typed earlier that we currently have Blue Shield, not Blue Cross. We helped one of the kids buy an Anthem Blue Cross policy more recently so Blue Cross was on my mind. So far so no issues with either one.
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Old 08-19-2016, 08:19 PM   #60
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This is probably an old joke but it was new to me. A dental student friend asked me what do you call the person who graduates last in his dental class? The answer was a dentist.
Actually, the answer is "Doctor".
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